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  The ATLS course points out that pregnant women who are Rh- and sustain significant blunt torso trauma should empirically receive Rhogam in case the fetus turns out to be Rh+. But there is one situation where men might receive it. Most trauma centers use O- blood as their universal donor units because it does not contain any major antigens. However, O- blood is uncommon. Worldwide, only 4-9% of the population have this blood type. In China, the incidence of O- blood is nearly zero! So busy centers that don’t have much O- may substitute O+ blood for men. They then switch to the proper blood type when the crossmatch is complete This makes sense, since men don’t ever have to worry about a Rh+ fetus. However, since this typically occurs at very busy (read: high penetrating injury) centers, there is a significant number of repeat offenders. And if they receive it again, the antibodies to the Rh factor they developed the first time can cause a significant hemolytic reaction. So men...

Delayed cerebral ischemia ( DCI ) is the most common cause of secondary neurologic injury in patients with aneurysmal subarachnoid hemorrhage ( SAH ). Intravascular volume depletion is one of several factors thought to cause, or worsen, DCI . Pulmonary edema frequently occurs in patients with SAH . A recent study in patients with SAH and pulmonary edema demonstrated that many were not volume overloaded.  In fact, many were intravascularly volume depleted. Think twice about aggressive diuresis in patients with SAH and pulmonary edema, as this may exacerbate volume depletion and may worsen DCI . References Scalfani MT, Diringer MN. Year in review 2010: Critical Care - neurocritical care. Crit Care 2011;15:237

The Swiss surgeon Theodore Kocher gave his name to: 1. A surgical incision. 2. An anaesthesia mask. 3. An orthopaedic manoeuvre. Theodore Kocher (1841-1917) was Professor of Surgery at Berne University. He won the Nobel prize in 1909 for improving the surgical techniques used during thyroidectomy. Kocher's incision is used for access to the gall-bladder. Kocher's mask was used for open drop chloroform and ether. Kocher's manoeuvre is used to reduce a dislocated shoulder

What and why of low flow anesthesia... Flow rates can be categorized into: Metabolic flow: 250 ml/mn Minimal flow: 250-500 ml/mn Low flow: 500-1000 ml/mn Medium flow: 1-2 L/mn High flow: 2-4 L/mn Super-high flow >4 L/mn Advantages of low flow anesthesia: -Anesthetic gases delivered using high FGF are usually dry and cold. Reducing FGF makes gases recirculating in the circle system more humid and warmer. This has A significant influence on the function and the integrity of the ciliated epithelium of the respiratory tract, prevent airway and bronchial drying during ETT use. It also helps maintain body heat and prevent postoperative shivering. -Several studies prove that the use of low and minimal flow anesthesia techniques can dramatically reduce the (annual) costs of volatile anesthetics. Typically, the reduction of FGF from 3 L/min to 1 L/min results in savings of about 50% of the total consumption of any volatile agent. Reduced FGF releases a lower amount of anesthetic agents int...

PDA Provides Systemic Flow Critical coarctation of the aorta Interrupted aortic arch Hypoplastic left heart syndrome         Critical aortic stenosis PDA Provides Pulmonary Flow Pulmonary atresia Critical pulmonic stenosis Severe subpulmonic stenosis with ventricular septal defect Tricuspid atresia with pulmonic stenosis  

Anesthetic Management Issues for Patients with Behcet's Disease -Puncture of skin or mucous membrane is very likely to result in inflammation and nodular formation and should be kept to a minimum. -Regional anesthesia would be less ideal but not contraindicated (Lesions from needle used for regional anesthesia) - Awake fiberoptic intubation would be required with topical local anesthetics to airway rather than airway blocks. -Use of an LMA could aggravate lesions in the airway. -If spinal cord lesions are symptomatic, use of succinylcholine can result in hyperkalemia. -With cervical cord lesions, intraoperative autonomic hyperreflexia may occur. -Consider stress-dose corticosteroids with chronic steroid use. -Behcet Disease may adversly affect pregnancy; the miscarriage, the pregnancy complications and C/section rates were significantly elevated.

The incidence of failed spinal after CSE is 5% ..better than old reports of 25%. 5causes for failed spinal: Smaller-gauge spinal needles with long lengths are typically used. These needles lead to slower return of CSF and a greater resistance to injection. Because the epidural needle has penetrated the tissue  planes, there is little to anchor the spinal needle in place. Although a Luer lock apparatus is available, it locks at a fixed needle length and can result in not reaching or traversing the dura. Any deviation from midline can lead to missing the dura altogether. If loss-of-resistance technique used saline, a false return of saline in the spinal needle rather than CSF can occur.it is recommended to use LOR with air . Finally, patient positioning and duration between spinal injection and completion of epidural catheter placement can change the characteristics of the spinal block Cook TM. Combined spinal-epidural techniques. Anaesthesia 2000;55:42–64. Goobie SM, M...

The topic of ‘clinical leadership’ has the habit of bringing up all sorts of responses which, with the increasing amount of airtime it’s receiving, are more and more frequently being debated. In my experience so far, views vary from those keen to understand more and get involved, to the unconverted who assume it’s just another means of a small group of clinicians drawing attention to their careers. This brings me onto the next issue, of why clinical leadership actually matters and whether it’s relevant to all doctors. Well, leadership and medicine have a long history together. For as long as people have sought health advice, doctors have been seen as leaders. All doctors, even F1s, are asked to lead clinical colleagues albeit in different capacities as we move through our training. What are we doing when we run a crash call…? Running a ward round…? Leading an audit project…? Doctors end up using some fairly sophisticated skills to manage these situations from their first days on the ...

This little known classic has never been repeated, but it has sparked a debate that continues to this day: What is the best direction to place a suppository – pointy or blunt end first? The authors challenged conventional wisdom as well as manufacturer instructions and tested their theory – that blunt end was best – on 100 unwitting patients. The rate of needing to insert a digit in the anal canal to push the suppository further in was 1% in the blunt end group versus 83% for pointy end first. Unwanted suppository expulsion rate was also lower in the blunt end group.  Since this is the only study of its kind, questions have been raised as to whether it should be practice changing.Also this study was done in 1991 and it is a call for further research. Abd-el-Maeboud KH, el-Naggar T, el-Hawi EM, Mahmoud SA, Abd-el-Hay S. Rectal suppository: commonsense and mode of insertion. Lancet. 1991 Sep 28;338(8770):798-800. PMID: 1681170

Obese pediatric patients do worse than their lean counterparts with respect to: Critical care (1)Obese children have longer ICU stays and. (2)Obese children have more complications ( sepsis and post-operative fistulas) . Surgical conditions (ex. Appendectomy) (1)Diagnosis is more difficult – more likely to have CT scans versus U/S (2)Increased risk for conversion of laproscopic to open procedure (3)Have increased surgical times (4)Have increased risk for wound infections Pulmonary conditions   (1)Longer length of stay for obese children admitted to ICU for status asthmaticus. (2)Increased risk for developing atelectasis (3)Have decreased chest wall compliance (4)Sleep-disordered breathing (OSA) is very common cause of morbidity affecting 37-46% of the obese pediatric population (45% of these patients still had symptoms even after tonsillectomy). Cardiopulmonary arrest (1)Obesity is independently associated with worse odds of event survival and surviving to hospital d...

The Use of steroids in Spinal cord trauma/injury is controversial topic ,some still belief it is helpful, and surely there are opponents who belief the opposite..the question what is the evidence? here were we are putting some of the literature findings...some findings support and another don't.. The original NASCIS trial (NASCIS I) found no difference in motor function or pinprick/sensation from baseline with IV methylprednisolone use, but the doses used were much lower than the doses used in the animal studies that first suggested a possible benefit.  Therefore, NASCIS II was performed to look at high dose methylprednisolone in acute spinal cord injury.  Patients received either methylprednisolone, naloxone, or placebo within the first twelve hours of injury.  The methylprednisolone was high dose and given for 24 hours.  Overall there was no benefit in the methylprednisolone group, but sub-group analysis showed a small benefit in motor function in the patien...

An important distinction needs to be made between specifically reducing heart rate vs. what is more typically done,which is reduction of heart rate with a Beta-adrenergic blocker. Besides decreasing heart rate,B-adrenergic blockade also can decrease cardiac contractility, alter metabolism, lead to decreased arterial resistance, and increase venous vascular resistance.The response to Beta-blockade is thus an integration of all these effects. Because heart rate is such an important determinant of myocardial oxygen demand, reduction of maximum heart rate as well as prevention of surges in heart rate make good sense in patients with fixed coronary obstructions and limitations in the coronary supply of oxygen. A series of studies showed beneficial effects of Beta-adrenergic antagonists in patients after myocardial infarction. There is also evident improvement in clinical symptoms and an improvement in work capacity with use of Beta-adrenergic blockers in patients with stable angin...

The three major determinants of myocardial oxygen demand are heart rate, contractility, and wall tension. Except at very high arterial pressures, changes in heart rate dominate the changes in energy demand, so that heart rate itself is an important indicator of myocardial oxygen demand. The supply of oxygen to the heart is determined by coronary blood flow, hemoglobin concentration, and the saturation of the hemoglobin molecules. Coronary blood flow is determined by the arterial pressure (especially in diastole for the left heart) and resistance to flow in the coronary arteries. When coronary vessels are normal, the reserve for coronary flow is very large and should be adequate even at heart rates 200 BPM .

Despite the  widespread measurement of heart rate. The  physiological implications of high and low heart rates are complex and not always fully appreciated. So in this post  we will discuss the basic Physiology Of HR and in the next posts we will go into the clinical aspects of HR. First :Parasympathetic input slows the discharge rate and Beta input increases it The intrinsic heart rate without any autonomic input was studied  by giving the muscarinic receptor antagonist atropine to block parasympathetic and the B1 adrenergic receptor antagonist propranolol to block sympathetic activity Healthy adults aged 16–70 yrs, the intrinsic heart rate was 106 beats/min There was an age-related decline in the intrinsic rate of 0.057 beats/min per year so that in a 60 yr old, intrinsic heart rate was only approximately 90 beats/min Because the normal resting heart rate is approximately 70 beats/min, parasympathetic input must dominate in the resting...

Owing partly to the assumption that adverse neurologic events were specifically related to the use of extracorporeal cardiopulmonary bypass, techniques were developed for performing CABG without the use of cardiopulmonary bypass (i.e., off-pump surgery). However, recent large, prospective, randomized studies comparing the rate of adverse neurologic outcomes after conventional on-pump surgery with the rate after off-pump surgery have not shown a significant risk reduction associated with the use of off-pump surgery. Consequently, efforts to reduce the incidence of postoperative neurologic injury have begun to focus on patient-related risk factors, such as the degree of atherosclerosis of the aorta, the carotid arteries, and the brain, rather than procedure-related variables

Risk Factors Associated With Ischemic Optic Neuropathy After Spinal Fusion Surgery Background : Perioperative visual loss, a rare but dreaded complication of spinal fusion surgery, is most commonly caused by ischemic optic neuropathy (ION). The authors sought to determine risk factors for ION in this setting. Methods : Using a multicenter case-control design, the authors compared 80 adult patients with ION from the American Society of Anesthesiologists Postoperative Visual Loss Registry with 315 adult control subjects without ION after spinal fusion surgery, randomly selected from 17 institutions, and matched by year of surgery. Preexisting medical conditions and perioperative factors were compared between patients and control subjects using stepwise multivariate analysis to assess factors that might predict ION. Results : After multivariate analysis, risk factors for ION after spinal fusion surgery included male sex (odds ratio [OR] 2.53, 95% CI 1.35–4.91, P = 0.005), obesity (OR 2....

The current Surviving Sepsis campaign guidelines recommend that vasopressin should not be administered as the initial vasopressor in septic shock, and that vasopressin at constant dosage of 0.03 units/min may be added to norepinephrine with anticipation of an effect equivalent to that of norepinephrine alone. European intensivists conducted a systematic review to determine vasopressin’s risks and benefits in vasodilatory shock. There was no demonstrated survival benefit but its use is associated with a significant reduction in norepinephrine requirement. Interestingly, the authors point out: ‘Low-dose vasopressin may help to restore blood pressure in patients with hypotension refractory to catecholamines, and may favor pulmonary vasodilation and increase glomerular filtration rate and plasma cortisol levels’. The  take home message: consider its use if an apparent vasodilatory shock state is refractory to catecholamines, but don’t stress if you don’t have access to it (or...

In January 12 post...The results of Randomised comparison IV paracetamol to Morphine showed that 1 g IV morphine is comparable to IV 10 mg of Morphine...But after re-reading the results you will discover that Morphine still the better option for acute pain management. Why the results of this study cannot be the trigger to shift into paracetamol instead of Morphine.. n = 55 so tiny numbers which is the single biggest problem paracetamol group had consistently higher pain (about 6mm) but it decreased in the same manner as the morophine group and they were of comparable efficacy neither group did that well (pain went from 75 to 55 over an hr) and 1/3 in each group wanted resuce meds they state a statistically significant increase in AEs in the morphine group but this was 8 vs 2 pts and they don’t tell us specifically what those AEs were more pts were satisfied in the morphine group. They conclude that a large trial is needed to answer this, and it seems that it probably does....

Besides Post Dural Puncture Headache, there is also a post-partum cervical myofascial pain syndrome. This is associated with a long second stage of labor and prolonged pushing. It is similar to PDPH in some respects with second-day onset and involvement of the occiput, neck and shoulder girdle. However, the pain does not change with posture, is associated with marked point tenderness of affected muscles and responds well to physical therapy.

The main advantage of sevoflurane over halothane is its remarkable cardiovascular safety. The cardiovascular effects of sevoflurane are similar to those of isoflurane. It does not sensitize the myocardium to exogenous or endogenous catecholamines, and thus promotes less arrhythmias than halothane especially during ENT surgery, dental surgery or endoscopies. Sevoflurane does not modify atrio-ventricular conduction time. Therefore, the incidence of bradycardia is much lower with sevoflurane than with halothane, especially in infants. Sevoflurane depresses myocardial contractility to a lesser extent than halothane does in infants and children . The latter is of greatest importance during induction especially in children with compromised cardiovascular function. Sevoflurane, as well as halothane and isoflurane, markedly depresses baroreflex control of heart rate in infants and children . On recovery, baroreflex control of heart rate is more rapidly restored after sevoflura...

Air embolism is  common complication during liver surgery specially when you are maintainig low CVP. The Cavitron ultrasonic aspirator (CUSA) is associated with less blood loss  than is a clamp-and-crush method. However, all CUSA patients had air emboli during hepatectomy.Air emboli occurred in 68% of patients undergoing clampand- crush hepatic resection. Air embolism is problematic during liver surgery and transplantation because of the risk of catastrophic paradoxical embolism. Paradoxical embolism need not occur through an intracardiac right-to-left defect. Many patients presenting for hepatic resection (and certainly most liver transplant patients) have cirrhosis, and many cirrhotic patients have abnormal arteriovenous connections in the pulmonary circulation. Massive venous embolism and/or paradoxical embolus must be high on the differential diagnosis of unexplained cardiopulmonary performance problems during hepatic resection

Begin with induction dose of propofol, 1 mg/kg (patient typically apneic for few seconds only; able to breathe spontaneously reasonably quickly); then, infuse with propofol, 100 µg/kg and titrate up or down as necessary; monitor capnography so patient breathing spontaneously but generally unresponsive to voice. sleep 1 —surgeon performs local anesthetic infiltration, applies pins, and places urinary catheter. patient awakened and allowed to remain awake during placement of drapes (knows what to expect during next awake period; gets used to manipulation); repeat propofol induction and infusion procedure (pin head holder then locked down).   sleep 2 —surgeon performs craniotomy and dural reflection. stop propofol infusion and allow patient to awaken (perform surface mapping or EEG recording). sleep 3 — onc e areas to be resected are identified, anesthetize patient once resection complete, patient reawakened (if EEG monitoring necessary, electrodes reapplied to verify elim...

The neurotransmitter pathways involved in the mechanism of postanesthetic shivering (PAS) are poorly understood. Meperidine, clonidine, and physostigmine are all effective treatments, indicating that opioid, [alpha]2-adrenergic, and anticholinergic systems are probably involved. We investigated the effect of ondansetron, a 5-HT3 antagonist used to treat postoperative nausea and vomiting, on intraoperative core and peripheral temperatures and PAS. Eighty-two patients (age, 18-60 yr) undergoing orthopedic, general, or urological surgery were randomized into three groups in this double-blinded, placebo-controlled, study: Group O4 (n = 27) received ondansetron 4 mg IV, Group O8 (n = 27) received ondansetron 8 mg IV, and Group C (n = 28) received saline IV immediately before the anesthetic induction.  In this  randomized, double-blinded, placebo-controlled, clinical study, ondansetron 8 mg IV, given just before the induction, reduced the incidence of postanesthetic shiv...

Last 7 years Deliver 30–45J max Indications EF <30% and prior MI EF <35% and prior MI and NYHA Class >1 EF <40% and prior VTach/VFib or inducible at EP testing AICD May Not Fire (High Defibrillation Threshold) when energy level sensed is too high to safely fire. Causes: Antiarrhytmics Cocaine/Illicit Drug Use Pneumothorax or COPD (high impedence) Poor lead placement Acidosis/Electrolyte abnormality Hypoxia Heart Failure EF <35% and prior MI and NYHA Class >1 some more pearls: AICD shock can cause transient EKG changes Magnet disables AICD function but not pacing function (puts it into asynchronous mode with fixed pacing). Place magnet, will beep, each beep is it sensing the QRS. Once constant tone, AICD is disabled. Re-place magnet for 30 seconds to re-activate If 1 magnet doesn’t disable (pt obese), place two magnets on top of each other. Shocks during CPR are not dangerous to provider. Place defibrillation pads 10cm from the pulse generator

Epidural Test dose are as important in Children as in adults. However since epidural block always done under general anesthesia, GA decrease test dose sensitivity. For example during halothane anesthesia administration of IV adrenaline causes hypertension and bradycardia not tachycardia. Prior administration of Atropine 0.01mg/kg increase the reliability of test dose during halothane anesthesia. During Sevoflurane anesthesia, the reliability of IV adrenaline test dose 0.01mg/kg is 100% using the 10 beat per minute increase in HR as definition of positive test dose. Atropine is not needed to achieve this sensitivity. There is no data regarding test dose during isoflurane   or desflurane anesthesia  

Randomised comparison of intravenous paracetamol and intravenous morphine for acute traumatic limb pain in the emergency department. Abstract Objective To compare the clinical effectiveness of intravenous paracetamol with intravenous morphine in patients with moderate to severe traumatic limb pain. Methods This randomised, double-blind pilot study was conducted in an urban UK emergency department. Patients between 16 and 65 years old with isolated limb trauma and in moderate to severe pain (pain score of 7 or more) received either 1 g intravenous paracetamol or 10 mg intravenous morphine sulphate over 15 min. The primary outcome measure was pain score measured on a visual analogue scale at 0, 5, 15, 30 and 60 min after commencing drug administration. The requirement for rescue analgesia and the frequency of adverse reactions were also recorded. Results 55 patients were recruited over 10 months. There was no significant difference in analgesic effect betw...

6 causes for hypotension in acute pancreatitis a) sequestration (3rd spacing) of protein rich fluids in and around the pancreas and abdominal cavity, retroperitoneum b) compounded by pre existing fluid depletion. c) direct myocardial depression d) SIRS / sepsis e) Intra-abd hypertension f) Bleeding

Recent evidence suggests equivalent, and possibly superior, outcomes when neonatal resuscitation is initiated with room air. Evidence of harm from oxygen therapy includes oxidative damage, as well as a possible association with increased rates of childhood malignancy. In 2010, the American Heart Association and the European Resuscitation Council recommend initial resuscitation with air rather than oxygen. The need for supplemental oxygen should be guided by a pulse oximeter attached to the right upper extremity (preductal). Blended air and oxygen should only be used if there is no improvement in oxygenation. Dawson et al. used a prospective cohort of 468 term and preterm infants to create reference ranges (3rd to 97th percentiles) for oxygen saturation measurements in the first 10 minutes of life. It is important to note that in term infants, it takes approximately 8 minutes to reach an oxygen saturation 90%, and slightly longer in preterm infants. The table below shows targeted oxyge...

    INTRODUCTION: Current European  Resuscitation  Council (ERC) guidelines recommend  intraosseous  (IO) vascular   access , if intravenous (IV)  access  is not readily available. Because  central   venous  catheterisation (CVC) is an established alternative for in-hospital  resuscitation , we compared IO  access   versus  landmark-based CVC in  adults  with difficult  peripheral   veins . METHODS: In this prospective observational study we investigated success rates on first attempt and procedure times of IO  access   versus   central   venous  catheterisation (CVC) in  adults  (≥18 years of age) with inaccessible   peripheral   veins   under  trauma or medical  resuscitation  in a level I trauma centre  emergency department . RESULTS: Forty consecutive  adults   under   resuscitation  were analyse...